2018–19 Kivu Ebola epidemic

This article is about the ongoing Ebola virus outbreak in the Democratic Republic of the Congo and Uganda. For the prior Ebola outbreak in DRC, see 2018 Équateur province Ebola outbreak.

The 2018–19 Kivu Ebola epidemic[note 2] began on 1 August 2018, when it was confirmed that four cases had tested positive for Ebola virus disease (EVD) in the eastern region of Kivu in the Democratic Republic of the Congo (DRC).[9][10][11] The Kivu outbreak includes Ituri Province, after the first case was confirmed on 13 August,[8] and in June 2019, the virus reached Uganda, having infected a 5-year-old Congolese boy who entered Uganda with his family.[12] but was contained. In November 2018, the outbreak became the biggest Ebola outbreak in the DRC's history,[13][14][15] and by November, it had become the second-largest Ebola outbreak in recorded history,[16][17][18] behind only the 2013–2016 West Africa epidemic. On 3 May 2019, nine months into the outbreak, the DRC outbreak death toll surpassed 1,000.[19][20]

Since January 2015, the affected province and general area have been experiencing a military conflict, which is hindering treatment and prevention efforts. The World Health Organization (WHO) has described the combination of military conflict and civilian distress as a potential "perfect storm" that could lead to a rapid worsening of the outbreak.[21][22] In May 2019, the WHO reported that since January there had been 42 attacks on health facilities and 85 health workers had been wounded or killed. In some areas, aid organizations have had to stop their work due to violence.[23] Health workers also have to deal with misinformation spread by opposing politicians.[24]

Due to the deteriorating situation in North Kivu and surrounding areas, the WHO raised the risk assessment at the national and regional level from "high" to "very high" in September 2018.[25] In October, the United Nations Security Council stressed that all armed hostility should come to a stop in the DRC, to better fight the ongoing EVD outbreak.[26][27][28] A confirmed case in Goma triggered the decision by the WHO to convene an emergency committee for the fourth time,[29][30] and on 17 July 2019, they announced a Public Health Emergency of International Concern, the highest level of alarm the WHO can sound.[31]

Contents

Figure 2. Map of the Democratic Republic of the Congo; North Kivu (orange, middle) South Kivu (dark red, bottom) and Ituri (green, top)

On 1 August 2018, the North Kivu health division notified Congo's health ministry of 26 cases of hemorrhagic fever, including 20 deaths. Four of six samples were sent for analysis to the National Institute of Biological Research in Kinshasa. Four of the six came back positive for Ebola and an outbreak was declared on that date.[33][34]
The index case is believed to have been the death and unsafe burial of a 65-year-old woman on 25 July in the town of Mangina; soon afterwards seven members of her immediate family died.[35] This outbreak started just days after the end of the outbreak in Équateur province.[36][37]

By 3 August, the virus had developed in multiple locations; cases were reported in five health zones – Beni, Butembo, Oicha, Musienene and Mabalako – in North Kivu province and additionally, Mandima and Mambasa in Ituri Province.[38] However, one month later there had been confirmed cases only in the Mabalako, Mandima, Beni and Oicha health zones. The five suspected cases in the Mambasa Health Zone proved not to be EVD; it was not possible to confirm the one probable case in the Musienene Health Zone and the two probable cases in the Butembo health zone. No new cases had been recorded in any of those health zones. The first confirmed case in Butembo was announced on 4 September, the same day that it was announced that one of the cases registered at Beni had actually come from the Kalunguta Health Zone.[39]

On 1 August, just after the Ebola epidemic had been declared, Doctors Without Borders/Médecins Sans Frontières (MSF) arrived in Mangina, the epicenter of the outbreak to mount a response against the outbreak.[40] On 2 August, Oxfam indicated it would be taking part in the response to this latest outbreak in the DRC.[41]
On 4 August, the World Health Organization (WHO) indicated that the current situation in the DRC, due to several factors, warranted a "high risk assessment" at the national and regional level for public health.[42]

In November, it was reported that the EVD outbreak ran across two provinces (and 14 health zones). The Table 1. Timeline of reported cases reflects cases that were not able to have a laboratory test sample prior to burial as probable cases.[43] By 23 December, the EVD outbreak had spread to more health zones, and at that time 18 such areas had been affected.[44] The current population in DRC is more than 84,000,000 people.[45]

The Uganda Ministry of Health has issued an alert for extra surveillance as the neighboring outbreak in the DRC is just 100 kilometres (62 mi) away from its border.[46] On 7 August, the DRC Ministry of Public Health indicated that the total count had climbed to almost 90 cases;[47] two days later, on 9 August, it was nearly 100 cases.[48] On 16 August, the United Kingdom indicated it would help with EVD diagnosis and monitoring in the Democratic Republic of the Congo.[49]
On 17 August, the WHO reported that "contacts" numbered about 1500 individuals, however there could be more in certain conflict zones in the DRC that can not be reached.[50] Some 954 contacts were successfully followed up on 18 August, however, Mandima Health Zone indicated resistance; as a consequence, contacts were not followed up there per the World Health Organization.[51]

On 4 September, Butembo, a city with almost one million people and an international airport, logged its first fatality in the Ebola outbreak. The city of Butembo, in the Democratic Republic of the Congo, has trade links to Uganda, which it borders.[52][39]

On 24 September, it was reported that all contact tracing and vaccinations would stop for the foreseeable future in Beni, due to an attack the day before by rebel groups that left several individuals dead.[53] On 25 September, Peter Salama of the World Health Organization indicated that insecurity is obstructing efforts to stop the virus and
believes a combination of factors could establish conditions for an epidemic.[54] On 18 October, the Centers for Disease Control and Prevention raised its travelers' alert to the Democratic Republic of the Congo from a level 1 to level 2 for all U.S. travelers.[55] On 26 October, the World Health Organization indicated that half of confirmed cases were not showing any fever symptom, thus making diagnosis more difficult.[56]

On 6 November, the Centers for Disease Control and Prevention (CDC) indicated that the current outbreak in the east region of the DRC may not be containable due to several factors. This would be the first time since 1976 that an outbreak has not been able to be curbed.[57] Due to various situations surrounding the current EVD outbreak, WHO indicated on 13 November, that the viral outbreak would last at least six months.[58]

On 23 November, it was reported that due to a steady increase in cases, it is expected that the EVD outbreak in DRC will overtake the Uganda 2000 outbreak of 425 total cases, to become the second biggest EVD outbreak behind only the West Africa Ebola virus epidemic.[59][17] According to the available statistics, women are being infected at a higher rate, 60%, than their male counterparts due to the EVD outbreak, a report issued 4 December indicated.[60]

On 29 December, the DRC Ministry of Public Health declared "0 new confirmed cases detected because of the paralysis of the activities of the response in Beni, Butembo, Komanda and Mabalako" and no vaccination has occurred for three consecutive days.[61] On 22 January the total case count began to approach 1,000 cases, (951 suspected, probable, confirmed) in the DRC Ministry of Public Health situation report.[62] The graphs below demonstrate the EVD intensity in different locations in the DRC, as well as in the West African epidemic of 2014–15 as a comparison:

Figure 3. New cases per week in Mabalako between 2018-07-16 and 2018-12-31

Figure 4. New cases per week in town Beni between 2018-07-23 and 2019-01-28

Figure 5. New cases per week in Butembo (brown) and Katwa (yellow) between 2018-07-23 and 2019-02-04

Figure 6. West Africa Ebola epidemic cases per week, for comparison with current outbreak

On 16 March, the director of the Centers for Disease Control and Prevention indicated that the outbreak in the Democratic Republic of the Congo could last another year, additionally indicating that vaccine supplies could run out.[63]

According to a September 2018 Lancet survey, 25% of respondents in Beni and Butembo believed the Ebola outbreak to be a hoax. These beliefs correlated with decreased likelihood of seeking healthcare or agreeing to vaccination.[64][65] Furthermore, according to the World Health Organization, resistance to vaccination in the Kaniyi health area was ongoing as of March 2019.[66]

On 16 August it was reported that the Ebola virus disease had spread to South Kivu (the third such province where this has occurred in DRC), via two new cases who had travelled from Beni, North Kivu.[67][68] By August 22 the number of cases in Mwenga had risen to four, including one person at a health facility visited by the first case.[69]

On 14 July 2019, the first case of EVD was confirmed in the capital of North Kivu, Goma, a city with an international airport and a highly mobile population of 2million people, which is right at the DRC's eastern border with Rwanda.[70][71][72][73] This case was a man who passed through three health checkpoints, with different names on traveller lists.[30] The WHO stated that he died in a treatment centre,[74] whereas according to Reuters he died en route to a treatment centre.[75] This case triggered the decision by the WHO to again reconvene an emergency committee,[29][30] at which the situation was officially announced as a PHEIC on 17 July 2019.[31]

On 30 July, a second case of EVD was confirmed in the city of Goma, apparently not linked to the first case,[76] and declared dead the following day.[77] Across the border from Goma in the country of Rwanda, Ebola simulation drills are being conducted at health facilities.[78] A third case of EVD was confirmed in Goma on 1 August.[79] On 22 August 2019, Nyiragongo Health Zone, the affected area on the outskirts of Goma, reached 21 days without further cases being confirmed.[80]

On 13 August 2018, the DRC reported a total of 115 cases of the virus within its borders so far.[8][81] A UN agency indicated that steps were being taken to ensure that those leaving the DRC into Uganda were not infected with Ebola, this being done via active screening.[8][81] The government of Uganda opened two Ebola treatment centers at the border with the Democratic Republic of the Congo, though there had not yet been any confirmed cases in the country of Uganda.[82][83] By 13 June 2019, nine treatment units were in place near the affected border.[84]

According to the International Red Cross, a 'most likely scenario' entails an asymptomatic case will at some point enter the country of Uganda undetected among the numerous refugees coming from the DRC.[85] On 20 September, Uganda indicated it was ready for immediate vaccination, should the Ebola virus be detected in any individual.[86][87]

On 21 September, officials of the Democratic Republic of the Congo indicated a confirmed case of EVD at Lake Albert, an entry point into Uganda, though no cases were then confirmed within Ugandan territory.[88][89]

On 2 November, it was reported that the Ugandan government would start vaccination of health workers along the border with the Democratic Republic of the Congo as a proactive measure against the virus.[90] Vaccinations started on 7 November, and by 13 June 2019, 4699 health workers at 165 sites had been vaccinated.[84] Proactive vaccination has also been carried out in South Sudan, with 1471 health workers vaccinated by 7 May 2019.[91]

On 2 January 2019, it was reported that refugee movement from the DRC to Uganda had increased after the presidential elections.[92] On 12 February, it was reported that 13 individuals had been isolated due to their contact with a suspected Ebola case in Uganda;[93] the lab results came back negative several hours later.[94]

On 11 June 2019, the WHO reported that the virus had spread to Uganda. A 5-year-old Congolese boy entered Uganda on the previous Sunday with his family to seek medical care. On 12 June, the WHO reported that the 5-year-old patient had died, while 2 more cases of Ebola infection within the same family were also confirmed.[12][95] On 14 June it was reported that there were 112 contacts since EVD was first detected in Uganda.[96] Ring vaccination of Ugandan contacts was scheduled to start on 15 June.[28] As of 18 June 2019, 275 contacts have been vaccinated per Uganda Ministry of Health.[97]

On 14 July an individual entered the country of Uganda from DRC while symptomatic for EVD; there is an ongoing search for contacts in Mpondwe.[100] On 24 July, Uganda marked the needed 42 day period without any EVD cases to be declared Ebola-free.[101] On 29 August, a 9-year-old Congolese girl became the fourth individual in Uganda to test positive for EVD when she crossed from the DRC into the district of Kasese.[102]

On 29 December, an American physician who was exposed to the Ebola virus (and who was non-symptomatic) was evacuated, and taken to the University of Nebraska Medical Center.[103][104] On 12 January, the individual was released after 21 days without symptoms.[105]

#These figures may increase when new cases are discovered, and fall consequently, when tests show cases were not Ebola-related.†DRC Ministry of Public Health‡indicates suspected cases were not counted towards CFR

The area in question, North Kivu, is in the middle of the Kivu Conflict, a military conflict with thousands of displaced refugees.[199][200] The affected area has about one million uprooted people and shares borders with Rwanda and Uganda, with cross border movement because of trade activities. The humanitarian crisis and deterioration of the security situation is expected to affect any response to the outbreak.[201][202]

On 24 August, it was reported that an Ebola-stricken physician had been in contact with some 97 individuals in an inaccessible military area, hence those 97 contacts could not be diagnosed.[208][209] In September, it was reported that 2 peacekeepers were attacked and wounded by rebel groups in Beni[210] and 14 individuals were killed in a military attack.[211] In September 2018, the World Health Organization's Deputy Director-General for Emergency Preparedness and Response described the combination of military conflict and civilian distress as a potential "perfect storm" that could lead to a rapid worsening of the outbreak.[21][22]

On 20 October, an armed rebel group in the DRC killed some 13 civilians and took 12 children as hostages. This attack occurred in Beni, the epicenter of the outbreak.[212][213] On 11 November, six people were killed in an attack by an armed rebel group in Beni; as a consequence vaccinations were suspended there.[214][215] In November 2018, a paper by the U.S. Center for Strategic and International Studies on the violence and the EVD outbreak indicated the situation might worsen depending on the result and response of presidential elections in the country in 2018.[216] Yet another attack reported on 17 November, in Beni by an armed rebel group forced the cessation of EVD containment efforts and WHO staff to evacuate to another DRC city for the time being.[217] Beni continues to be the site of attacks by militant groups as 18 civilians were killed on 6 December.[218] On 22 December it was reported that elections for the President of the Democratic Republic of the Congo would go forward despite the EVD outbreak, including in the Ebola-stricken area of Beni.[219] Four days later, on 26 December, the DRC government reversed itself to indicate those Ebola-stricken areas, such as Beni, would not vote for several months;[220] as a consequence election protesters ransacked an Ebola assessment center in Beni just 24 hours later.[221][222][223] Post election tensions continued when it was reported that the DRC government had cut-off internet connections for the population, as the vote results were yet to be released.[224]

On 29 December, Oxfam said it would suspend its work due to the ongoing violence in the DRC;[225] on the same day, the International Rescue Committee suspended their Ebola support efforts as well.[226]

On 18 January, the African Union indicated that presidential election results announcements should be suspended in the Democratic Republic of the Congo, and have furthermore decided not to travel to the DRC.[227]

On 12 June 2019, in Uganda, a 5-year-old boy became the first cross-border victim of Ebola, with two more people testing positive for Ebola.[228] This shows the spread of Ebola to neighboring countries because of rebel attacks and community resistance hampering virus containment work in eastern Congo.[228]

Zaire ebolavirus strain is the most lethal of the six known strains (including the newly discovered Bombali strain);[230] it is fatal in up to 90% of cases.[231] Both Ebola and Marburg virus are part of the Filoviridae family.[232]

A significant part of the actual EVD infection is based on immune suppression. When an individual is infected the pathophysiological process indicates that as systemic inflammation sets in there are coagulation problems, as well as vascular and the aforementioned immune system issues.[236]

Contact tracing is a way of identifying those who have been in direct contact with an infected individual and are thus at higher risk of becoming infected or infecting others. Such individuals are monitored for up to 21 days in the case of EVD.[237][238]

On 26 July, it was reported that the country of Saudi Arabia would not allow visas from the Democratic Republic of the Congo after the World Health Organization (WHO) declared an International emergency due to EVD.[239]

On 1 August, the country of Rwanda closed its border with the Democratic Republic of the Congo, due to multiple cases in the city of Goma which borders the country in the upper Northwestern region.[240]

On 27 August, the World Health Organization evaluated the benefits and risks of drug treatment for EVD: Remdesivir, ZMapp, REGN3470-3471-3479, mAb114 and favipiravir.[241]mAb114 (which is a monoclonal antibody) is being used for the first time to treat infected individuals during this EVD outbreak.[242] An alternative treatment of ZMapp has not been used because it requires storage at −20 °C (−4 °F).[8]

On 25 November, the Democratic Republic of the Congo gave approval to start clinical trials for Ebola (EVD) treatment. Medical authorities will not choose which of the four experimental treatments will be given to an individual; instead it will be randomized.[243]

On 12 August, for the first time, two clinical trial medications were found to improve the rate of survival in those infected by EVD. They are REGN-EB3, a cocktail of three monoclonal Ebola antibodies, and mAb114. These two will be further used in therapy, ZMapp has been discontinued.[244][245][246][247]

On 8 August 2018, the process of vaccination began with rVSV-ZEBOVEbola vaccine.[249] While several studies have shown the vaccine to be safe and protective against the virus, additional research is needed before it can be licensed. Consequently, the WHO reports that it is being used under a ring vaccination strategy with what is known as "compassionate use" to protect persons at highest risk of the Ebola outbreak, i.e. contacts of those infected, contacts of those contacts, and front-line medical personnel.[250]

Based on a lack of evidence about the safety of the vaccine during pregnancy, the DRC ministry of health and the WHO decided to not vaccinate women who are pregnant or lactating. This decision has been criticized as "utterly indefensible" from an ethical perspective by some authorities. They note that as caregivers of the sick, pregnant and lactating women are more likely to contract Ebola. They also note that since it is known that almost 100% of pregnant women who contract Ebola will die, a safety concern should not be a deciding factor.[251] As of June 2019, pregnant and lactating women were also being vaccinated.[252]

The Democratic Republic of the Congo Ministry of Public Health reported on 16 August 2018 that 316 individuals had been vaccinated.[253] On 24 August, the DRC indicated it had vaccinated 2,957 individuals, including 1,422 in Mabalako against the Ebola virus.[254] By late October, more than 20,000 individuals had been vaccinated.[255] In December, Dr. Peter Salama, who is Deputy Director-General of Emergency Preparedness and Response for WHO, reported that the current 300,000 vaccine stockpile may not be enough to contain this EVD outbreak; additionally it takes several months to make more of the Zaire EVD vaccine (rVSV-ZEBOV).[256][257] On 11 December, it was reported that the stock of vaccine in Beni was 4,290 doses.[148]

As of August 2019, Merck & Co, the producers of the vaccine in use, reported a stockpile sufficient for 500,000 individuals, with more in production.[258]

In April 2019, the WHO published the preliminary results of its research, in association with the DRC's Institut National pour la Recherche Biomedicale, into the effectiveness of the ring vaccination program, including data from 93,965 at-risk people who had been vaccinated. WHO stated that the rVSV-ZEBOV-GP vaccine had been 97.5% effective at stopping Ebola transmission, relative to no vaccination.[259][260] The vaccine had also reduced mortality among those who were infected after vaccination. The ring vaccination strategy was effective at reducing EVD in contacts of contacts (tertiary cases), with only two such cases being reported.[260]

In August 2018, it was reported that the Mangina Ebola Treatment Center was operational.[261][262] A fourth Ebola Treatment Center (after those in Mangina, Beni and Butembo) was inaugurated in September in Makeke in the Mandima Health Zone of Ituri Province.[263] Makeke is less than five kilometers from Mangina along a well-traveled local road; the site had been proposed in August when it appeared that a second Ebola Treatment Center would be needed in the area, and space was insufficient in Mangina itself to accommodate one.[264] By mid-September, however, there had been only two additional cases in the Mandima Health Zone, and only sporadic cases were being reported in the Mabalako Health Zone.[265]

In February 2019, it was reported that attacks at treatment centers had been carried out in Butembo and Katwa. The motives behind the attacks were unclear. Due to the violence, international aid organizations had to stop their work in the two communities.[266][267] In April, an epidemiologist from WHO was killed and two health workers injured in a militia attack on Butembo University Hospital in Katwa.[268] In May, WHO's health emergencies chief said insecurity had become a "major impediment" to controlling the outbreak. He reports that since January there have been 42 attacks on health facilities and 85 health workers have been wounded or killed. "Every time we have managed to regain control over the virus and contain its spread, we have suffered major, major security events. We are anticipating a scenario of continued intense transmission."[23]

Health workers must don personal protection equipment during treatment of those affected by the virus, as well as various other tasks.[269]
On 3 September, WHO stated that 16 health workers had contracted the virus.[118]
On 10 December, the WHO reported that the current DRC outbreak had affected 49 healthcare workers as confirmed cases, and 15 had died.[147]
As of 30 April 2019, there have been 92 health care workers in the Democratic Republic of the Congo infected with EVD, of which 33 have died.[270]

On 5 October 2018, the Nobel Peace Prize was awarded to Denis Mukwege, who tends to the female victims of the ongoing internal armed conflict in the Democratic Republic of the Congo.[271]

In terms of prognosis, aside from the possible effects of post-Ebola syndrome,[272] there is also the reality of survivors returning to communities where they might be shunned due to the fear many have in the respective areas of the Ebola virus,[273][274] hence psychosocial assistance is needed.[275]

Post-Ebola syndrome signs and symptoms in an individual may include, but are not limited to the following:[276][277]

The Ebola virus disease outbreak in Zaire (Yambuku) started in late 1976, and was the second outbreak ever after the earlier one in Sudan the same year.[278][279] On 1 August 2018, the tenth Ebola outbreak was declared in the Democratic Republic of Congo, only a few days after the prior outbreak in the same country had been declared over on 24 July.[36][37]

World Health Organization chief Tedros Adhanom Ghebreyesus indicated on 15 August, that the current outbreak in DRC may be worse than the West Africa outbreak of 2013–2016,[280] due to several factors.[281]

The table below indicates the ten outbreaks that have occurred in the Democratic Republic of the Congo since 1976:

This map shows previous EVD outbreaks in the area of central Africa, which includes the Democratic Republic of the Congo. This outbreak is the biggest of the ten recorded outbreaks that have occurred in the DRC.[292]

Until the outbreak in North Kivu in 2018, no outbreak had surpassed 320 total cases in the Democratic Republic of the Congo. As of 24 February 2019, the outbreak has surpassed 1,000 total cases (1,048) and has yet to be brought under control.[298][283]

On 10 May, the U.S. Centers for Disease control and Prevention indicated that the outbreak could well surpass the West Africa epidemic given time.[299]

The 12 May issue of WHO Weekly Bulletin on Outbreaks and Other Emergencies, indicates that "continued increase in the number of new EVD cases in the Democratic Republic of the Congo is worrying...no end in sight to the difficult security situation".[179]

One way to measure the outbreak is the basic reproduction number, R0, a statistical measure of the average number of people expected to be infected by one person who has a disease. If the rate is less than 1, the infection dies out; if it is greater than 1, the infection continues to spread—with exponential growth in the number of cases.[300] A March 2019, paper by Tariq, et al. indicated (rho = −0.37, p < 0.001) oscillating around 0.9 for mean R.[301]

Following the confirmation of Ebola crossing into Uganda, a third review by the WHO on 14 June 2019,[27] concluded that while the outbreak was a health emergency in the DRC and the region, it does not meet all the three criteria for a PHEIC.[28] Following a case in Goma, the reconvening of a fourth review was announced on 15 July 2019.[30] The WHO officially announced it as a PHEIC on 17 July 2019.[31]

Financial support has been contributed by the governments of the US and the UK, among others. The UK DfID minister, Rory Stewart, visited the area in July 2019, and called for other western countries, including Canada, France and Germany, to donate more financial aid. He identified a funding deficit of $100–300million to continue responding to the outbreak until December, for example to pay for ring vaccination. He urged WHO to classify the situation as a PHEIC, to facilitate the release of international aid.[304][305]

^...in the Congolese statistics cases of Mabalako. Uganda's index case and 7 other family members were classified in Mabalako, the health zone where they started to develop symptoms. Of these 8 confirmed cases of the same family, 5 remained in the DRC and 3 had crossed the border. [...] The 2 deaths of Bwera are the 5-year-old boy and the 50-year-old grandmother who were classified...[7]

^Ituri province was added to N. Kivu province, in terms of viral infection, when the first case of EVD was confirmed on 13 August.[8]

^Schlein, Lisa. "WHO Warns Ebola Spreading in Eastern DR Congo". VOA. Retrieved 25 September 2018. A perfect storm of active conflict limiting our ability to access civilians, distress by segments of the community already traumatized by decades of conflict and of murder, driven by a fear of a terrifying disease

^McNeil Jr., Donald G. (12 August 2019). "A Cure for Ebola? Two New Treatments Prove Highly Effective in Congo". The New York Times. Retrieved 12 August 2019. The two new therapies were among four that were tested in a trial that has enrolled almost 700 patients since November. The two worked so well that a committee meeting on Friday to look at preliminary results in the first 499 patients immediately recommended that the other two treatments, ZMapp, made by Mapp Biopharmaceutical, and remdesivir, made by Gilead Sciences, be stopped. All patients will now be offered either the Regeneron or the Biotherapeutics drug.